Refer a Patient

Please fill out the information below completely and a staff member from Scottish Rite for Children will contact your patient's family/guardian to schedule an appointment and answer any questions. Referrals for dyslexia/learning disorders should be directed to the Center for Dyslexia Application Process section of the Dyslexia page.

Note: If you are a parent or guardian of a patient, please complete the Patient Online Appointment Request.

Preferred Location
Preferred Location
REFERRING PROVIDER INFORMATION
PRACTICE INFORMATION
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PATIENT INFORMATION
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PARENT / GUARDIAN INFORMATION
APPOINTMENT INFORMATION